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February 25, 2010

UCSF Study Shows Absence of Bias in Commercially Supported CME


Michael A. Steinman, MD, et al., recently examined the “Commercial Influence and Learner-Perceived Bias in Continuing Medical Education.” The article, which appeared in the Journal of Academic Medicine, examined the relationship between commercial support of continuing medical education (CME) and perceived bias in the content of these activities.




The research collected data from 213 directly sponsored live CME activities hosted by the University of California, San Francisco (UCSF) Office of Continuing Medical Education from 2005 to 2007. The median number of participants per course was 132.

The breakdown of CME activities included one third (73, or 34%) of courses with no commercial support, with the remaining courses split between varying levels of commercial support. One hundred seventy (80%) activities were considered at lowest risk of commercial bias based on the UCSF Office of CME’s risk rating system, 36 (17%) were considered intermediate risk, and 7 (3%) were considered highest risk.

Commercial support covered only 20%–49% of costs for 45 (21%) of the educational activities, and only 50% of costs for 46 activities (22%).


A standard question from course evaluations was used to determine the degree to which attendees believed commercial bias was present. At the completion of CME activities, participants were asked to evaluate several characteristics of the activity, including an overall rating of the course (using a five-point Likert scale) and a question about whether the activity was free of commercial bias (answered with a yes/no response). The study also evaluated other factors such as whether the activity chair had ties with industry or whether registration fees were below market value.




Overall, the data indicated that “the vast majority of CME activities were perceived by participants to be free of commercial bias.” Findings included:


- The perceived overall quality of CME activities was high, with a mean rating of 4.4 on a five-point Likert scale;


- Few course participants perceived commercial bias, with a median of 97% of respondents stating that the activity they attended was free of commercial bias;


- There was no association between extent of commercial support and the degree of perceived bias in CME activities; and


- Perceived bias did not vary for 11 of 12 event characteristics evaluated as potential sources of commercial bias, or by score on a risk index designed to prospectively assess risk of commercial bias.




Although criticisms have continued to grow over the past few years regarding commercial support for accredited CME, these concerns are misguided as yet another study shows. Moreover, “many organizations including the Accreditation Council for Continuing Medical Education (ACCME) and the Association of American Medical Colleges, have chosen to preserve commercial support,” a signal showing the importance of defending this relationship. In fact, these organizations support the continued funding of CME by industry while simultaneously “adopting increasingly more stringent regulations designed to limit the influence of industry funding on the content and objectivity of CME,” thereby negating any potential concerns.


In addition to the efforts of the previously mentioned organizations, non-profit providers of CME, such as academic medical centers (AMCs) and professional organizations “have adopted screening processes to identify activities at high risk of commercial influence,” including UCSF, as is described in the study.


Another source of evidence to silence critics of industry funded CME are the attempts made by the Consortium of Continuing Academic Medical Education, who have recently developed standardized instruments to predict bias in CME. Such tools are crucial in identifying potentially high risk of commercial bias in CME, while still preserving courses and funding. Consequently, these tools, and the evidence from UCSF’s study gave the “direct interpretation that CME activities in general are free of commercial bias.”




Dr. Steinman et. al, noted a few limitations in their study, such as the UCSF Office of CME rejecting proposals with a single industry supporter or those with no cost to the participant. As a result, the authors noted the screening process may have weeded out CME activities at higher risk of commercial bias, leaving only activities in which commercial bias was more subtle or entirely absent. Such a limitation is not troublesome because many critics of industry funded CME believe that programs with subtle bias are the hardest to discern for that very reason.


UCSF’s screening process to include CME activities may have also subjected to some programs to mitigation procedures before and/or during the activity. The authors also felt that using a simple “yes/no” question to assess learners’ perceptions of bias may have been a weakness. This suggestion is also unnecessary because the result gives highly trained doctors and attendees a clear answer, not a scale.




While the authors contend that their data shows the difficulty of detecting commercial bias in CME, their recommendation to safeguard against industry is not needed. Since their data shows that “the UCSF Office of CME’s screening practices resulted in a series of CME programs with little if any bias,” how could they contradict such results?


The fact that such a large number of programs (213) “were perceived by participants to be free of commercial bias,” suggests that CME programs at UCSF are maintaining the best kind of programs with physician’s while preserving collaboration with industry. Moreover, because “rates of perceived commercial bias were consistently low regardless of the presence or absence of risk factors for commercial bias,” any criticisms of industry-funded CME (at least at UCSF) are negated by this study.


Additionally, because the rates of perceived bias also “did not differ by the degree of industry support or other event characteristics,” the level of funding and involvement of single or multiple sources of funding from industry should no longer be a concern, as long as all ACCME standards and rules are followed.


Ultimately, while the authors recommend that more research “is needed to systematically investigate the presence and impact of bias in CME, including in-depth explorations of course content and learner perceptions of bias,” their present study nonetheless is a great starting point for maintaining industry funded CME. With the continuing trend of studies showing that industry funded CME programs have low rates of perceived commercial bias, and that commercial support does not result in perceived bias in CME activities, it seems like people are starting to recognize the important collaboration that industry and medicine have.


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